Souza, G. F. J.*

*Psychiatric Physician

Supervisor for interns at "Hospital das Clínicas"

UFMG (Federal University of Minas Gerais) - Brazil

SUMMARY

This paper reviews the broad concept of delusion by subjecting it to the natural difficulties of its phenomenological features for those atypical psychoses, usually manifested by patients with borderline personality disorder. In order to achieve this aim, the author presents two clinical cases. The first one refers to delusional disorder and the second case is about atypical psychosis which is referred to as psychoid state. After reviewing the classical features of the delusional experiences described in the first case, this study analyses the psychopathological characteristics of the latter and comes to the conclusion that there probably is a phenomenological spectrum, and perhaps nosological, which consists of manifestations ranging from those of personality disorders to the ones typical of psychotic disorders.

Key Words: Delusion, Phenomenology, Delusional Disorders, Personality Disorders, Atypical Psychoses, Psychoid States.

INTRODUCTION

The psychopathological morphology for many psychotic pictures seems to have been presenting some variations regarding the nature and actual multiplicity of those anomalous experiences reported by patients. Therefore, after reviewing the specialised literature and analysing written communications and verbal reports of other colleagues in addition to observing hundreds of cases throughout two decades of daily psychiatric practice, we could see that the psychopathological material presented to us is, on many occasions, phenomenologically atypical and uncharacteristic. Moreover, the observation of the clinical development of many cases raises important doubts about the definite diagnosis due to the symptomatological metamorphosis itself and sudden and unpredictable fluctuations of the psychopathological intensity of those experiences as well as their nature or intrinsic character.

At times, what seemed to be a clearly outlined and phenomenologically well-determined experience suddenly transmuted itself and overlapped with another category of anomalous experiences, decisively confusing the diagnostic evaluation and hence jeopardising the uniformity of therapeutic procedures as they are subjected to regular changes, not always desirable. In many cases, we are unable to distinguish safely whether a given judgement is classically regarded as a delusion or an overvalued idea, or whether some highly unlikely convictions which emerged in a certain moment of the patient's life are the result of a long abnormal development of personality or corresponded to a kind of 'circumscript' processual onset(8). In other cases, we met some anomalous experiences different from the classical standard of phenomenological report and which seemed more to consist of clinical elements resulting from the incomplete and abortive development of the symptomatological set of traditional endogenous psychoses(26) than of a psychopathological material which is unclassifiable at first and relegated to a disregarded taxonomic compartment of DSM-IV under the title of 'Psychotic Disorder Not Otherwise Specified'(2). As far as this classification is concerned, according to DSM-IV, this diagnostic compartment, reserved to include those semiologic 'remnants' which do not fit into any other typical symptomatological moulds throughout the development of the diagnosis exercise of psychotic pictures, is likely to bring more loss than benefits for psychiatric practice in general. This can stimulate ¾ and that is the major problem of criterial diagnosis ¾ the crystallisation of a simplistic, artificially static and compartmentalised view of psychic impairment and hence impoverish enormously the physician's personal resources for empathetically catching and absorbing those morbid experiences.

Nowadays, it seems that, in our environment, besides those typical processual diseases ¾ such as schizophrenia with its typical symptoms, subtypes and clinical history ¾ atypical and mixed psychotic pictures abound and multiply, such as some schizo-affective clinical forms followed by singular behavioural changes and experiences as well as others corresponding to psychotic complications in patients with personality disorder with similar characteristics.

We now present two clinical cases we had the opportunity to attend in our medical office, having in mind the theoretical discussion which follows, in which we discuss doubts and controversies concerning the diagnosis of some pictures, in an attempt to better characterise some atypical and ambiguous semiologic elements,

CASE REPORTS

Case 1

K. was thirty-one years old, married, white, and agronomist but working in the sales business at the time. He was brought for an examination by his wife due to a permanent state of nervousness and lack of confidence when facing minor problems. He was polite and spoke easily, fluently, properly and coherently about the symptoms afflicting him. He was also active, decisive and hard-working, regarded himself as an anxious person and believed the pressures suffered at work, the stress of the sales business, especially from September to January every year, were responsible for his state of tension and anxiety. When talking, he looked contracted and gloomy, showing concern and some restlessness.

He said he used to drink heavily from fifteen to twenty-nine years old and the alcohol did not do him any good. He had managed to quit drinking totally about two years before. He was impulsive, liable to overeating and compulsive gambling, characteristics criticised and disapproved by his wife, although the marriage seemed harmonic and the conjugal relationship rather satisfying. He said he often found himself very insecure and indecisive to solve daily difficulties and in those moments experienced a sort of distressing and restless expectation mingled with gloomy feelings. Other symptoms of the depressive constellation could not be seen, apart from some specific complaints about bad night sleep on some occasions.

As for his medical history, K. informed me he had been a hyperactive child and he had been extremely shy since his adolescence and early resorted to alcohol to feel more comfortable among other people.

At the end of the first examination, my diagnostic impression was that it was a mild picture of general anxiety disorder in a personality with avoidant and fearful traits and dysthymic fluctuations. He was prescribed fluoxetine 20mg/day and recommended to return after one month for another evaluation.

After thirty days, K. returned to my office. His appearance was slightly milder and he said he was a little better. Indeed, the quality of his sleep had improved and his lack of confidence and anxiety reduced. Nevertheless, his appearance was still a little heavy and circumspect. After talking about his anxiety symptoms, K., to my surprise, started recounting several facts which had happened three years before, just before his wedding, and had intrigued him considerably.

In short, ordering the facts, what he said can be described as following: about four years before, one night, after arguing with his fiancée, he went out on his own to "chase" girls. He met one who accepted his invitation to "go for a drive". As he had parked his car in an uninhabited area, he tried a more intimate physical contact with her and that was when the girl repelled him strictly, rushed out of the car and ran hastily, vanishing from the place. About a month later, he received a telephone call supposedly from the girl's father who, after identifying himself, reprimanded and threatened him. At first, he was a little shocked, but after considering he had done nothing wrong, forgot the incident completely after some months.

Over a year had passed when, one day, K. was driving his van on a local road heading for a certain farm where he would deliver his cargo when suddenly he felt an extraordinary sequence of facts happening. At first, he felt he was being followed and watched on the road. He noticed that some cars were following him, slowly at the beginning and then would overtake him very quickly and park somewhere ahead, mainly after a bent. The drivers of those cars came out of the vehicles and stood beside them, trying to pretend and disguise something. They sometimes feigned changing a flat tyre or sometimes pretended to detect another mechanic failure, but always avoiding looking at him directly. K. felt seriously threatened. He noticed that the road, which was usually empty and silent, was now strangely crowded and busy. He started panicking and decided to slow down considerably and let any car behind him overtake. Then, after everyone had overtaken him, he turned round and went hastily, through a short cut, towards a garage whose owner he knew and was the only protection he had along that road. When he arrived there, to his surprise, he saw two of the drivers who had taken part in his pursuit talking calmly to the owner of the garage. Overwhelmed by anger and astonishment, but controlling himself stealthfully, K. approached and found out that they had asked where a certain farm was. "To feign" he thought. After the strangers had left he asked who they were. "Apparently, they are going to farm X to take some measures ..." answered his acquaintance. To sum up, those enigmatic and extraordinary facts which had happened three years before, were the ones to make a strong impression on K.

After listening to all his stories silently, I asked if apart from that there had been any other odd and obscure fact in which he had been the protagonist. K. replied there was. About ten years before, he had a love affair with a woman older than him with whom he fell in love. The woman was very pretty, rich and lived with a maid who was black and had been her companion for many years. After some time, he became suspicious that there was a mutual sexual interest between them which they wittily tried to conceal. However, once, when they spent a short time together in the bathroom, he was sure he heard insinuations and erotic words of praise said by the maid to his girlfriend. On another occasion, when kissing her on the neck, he perceived a strong and pungent smell in her skin, 'an odour typical of coloured people'. He cunningly managed to lie on her lap and could clearly sense the same typical smell. His suspicions were confirmed when he got up, went to the kitchen and found the maid sitting, with half-shut eyes and 'extremely pale'. According to him, those evidences were strong enough to prove the affective link between the two women and he was so upset that he broke up on the same day, although he was very found of her.

As time passed, those facts fell into oblivion, but even in relation to his wife, since the time when they were dating, he had been noticing several 'weird things' happening between her and her flatmates. Many times, he could see episodes when his fiancée and a colleague were 'making eyes at each other' suggesting mutual interest. On other occasions, he could clearly notice some kind of secretly 'codified' communication between them. For instance, one day, when he went to pick her up, he noticed one of her colleagues pointing at her wrist watch insistently and looking at her suggestively, which for him, undoubtedly, meant a disguised arrangement for a date. According to him, since that time, although he had never confessed his doubts frankly to his wife, he had been trying to "find out" and discretely investigate her behaviour. He would sometimes suggest or comment something suspicious in her presence, but until then he had not been able to obtain a definite 'confession' from her. At times, he felt a sudden urge to expose her, but managed to control himself as he liked her very much and thought she was a good wife. Recently, he had been very suspicious, especially concerning his wife and her colleague from the office and was confused by some things he occasionally noticed. However, for his relief, her co-worker was moving to another city and would definitely be away from his wife. K. talked seriously and deeply about all that and, at no time, felt doubts about the credibility of his convictions. He nevertheless said he always tried 'not to be defeated' by those impressions, which disturbed and humiliated him so much.

Case 2

I.G. was twenty three years old, single, white and a primary school teacher and came to my office for the first time in July 1985. She was brought by her parents and listened to them telling me her behaviour had been changing since 1983. In December of that year, she was rather disturbed, saying that 'the world would end in fire'. On that occasion, she received an intensive medicamental and psychotherapeutic outpatient treatment in a clinic for four months. She was given bromazepam associated with maprotiline at low dosages and the acute crisis was entirely reverted. However, since January of 1985, I.G. had been different, unstable and fickle. She demanded for her parents to take her everywhere because she was 'frightened and shy', including to the school where she worked and where she felt everyone was watching her incessantly. She was having defiant insomnia and the lights of her bedroom remained on during all night. In the examination, when we had the chance to talk in private, I could observe that, in spite of her mild hostility, her affective dimension was apparently kept intact and preserved. She seemed to be clever and the verbal contact was good as she expressed herself fluently, thoroughly and accurately. She told me that at the time when she had her acute crisis, in December of 1983, she believed she 'could foresee things' and, on thirty-first December of that year, she was overwhelmed by deep anxiety because she firmly believed something serious and of great extent would occur. She started having some apocalyptic intuitions about the end of the world and, after some time, limited herself to her bedroom as it was the only place where she felt a little protected. At that time, her conviction was that the world was about to be invaded and destroyed by an ocean of fire, and her body would disappear, her soul would flow and dissipate completely.

Despite her improvement, I.G. said she was still frequently frightened and anxious. She believed her colleagues at school watched her and talked about her. Wherever she went, she felt embarrassed and watched. At the time of the appointment, she liked to be on her own, away from everyone and trusted nobody.

My diagnosis was that she had an undifferentiated and brief psychotic disorder and she was prescribed haloperidol (5 mg/day) associated with biperiden (2 mg/day) and suggested a weekly psychotherapeutic treatment.

Since then, throughout all those years, I have had the opportunity to observe her clinical development closely and meticulously, thanks to her strict discipline to follow the treatment and her great desire to be cured. At first, she felt better with the neuroleptic prescribed but, after some weeks, she was struck by boredom, muscular weakness, restlessness and insomnia and I was forced to replace haloperidol with trifluoperazine (5 mg/day), with success. Since the beginning of the psychotherapeutic treatment, I.G. gradually started revealing crucial doubts and thoughts that disturbed her continuously. She said she had been a child apparently with no serious health problems although very shy and withdrawn and preferred to play alone all the time. The first menstruation came at thirteen years old and after that she started feeling very embarrassed, especially because of her body. She thought she was fat and even went through some episodes of bulimia (overeating and inducing vomiting afterwards). There had always been an interest in man, but her excessive shyness deprived her of having dates, except for a short one at the age of eighteen.

She continued finding herself ugly and awkward and could notice this kind of constraint increased gradually. In her early twenties, she started feeling particularly anxious and apprehensive and some vague and indefinite suspicions and distrust crossed her mind. On an occasion, she was teaching in a school located next to a factory, in the industrial area of the city, when she was suddenly struck by a conviction that there would be an 'extensive leakage of lethal gases'. According to her, prior to that conviction she had scented 'the terrible smell of poisonous gases spreading around the school'. As she was very anxious and fearful, she received a sick leave and was laid off. At home, to spend time and calm down, she started reading a science-fiction novel named 'Eram os Deuses Astronautas', a resounding popular success in the seventies. That was precisely when her anomalous and apocalyptic convictions began ¾ that 'the world would end in fire'.

However, in her accounts, in contrast with her psychotic experiences, I.G. seemed to be a neurotic patient with an important histrionic component, anxious, restless, suggestible, impressionable, subject to sudden changes of mood. She was very responsible and committed to her work and duties, showing loftiness and pride. She described her misfortune with a stern face and a gleam of hatred in her look and, as time passed, showed distrust, rudeness, irony, dismay, bad mood, and rarely, affability and benevolence. She also said that on her first crisis she was treated in a clinic in which there was a physician and several psychologists and she began suspecting that they all thought she was 'homosexual'. Later, she noticed clearly, by the way the psychologists treated her, with some subtle insinuations and gestures, that she was actually homosexual. That was unbearable and unacceptable for her as, by her own accounts, at any moment of her life, she had never felt any desire for other people of the same sex, although she had had some clearly anomalous perceptions when attending public places.

Once, she was at a supermarket with her father when she felt she was being observed and criticised by the bystanders and was so embarrassed she had to rush out. On another occasion, she got on a bus and noticed that there were two young men chatting and, after squinting at her, commented 'nowadays, we never know who is a man and who is a woman'. She firmly believed that everyone was criticising her body and her feet in particular, which she considered to be too big and shapeless, in other words, typically 'masculine'. At twenty, she underwent a bunion surgery to 'improve the appearance' of that part of her body. When she looked at herself in the mirror, she felt distressed as she thought she had a male-shaped body, by her own accounts, similar to the caricatural traits of a 'transvestite'. That tormented her considerably and made her totally afflicted and with no strength. Moreover, at times, she motivelessly felt a fantasied urge to inflict a wound upon her genitals.

Those convictions were a little bizarre and curious, considering I.G. was a tall, slim woman, with delicate features. She nevertheless continued manifesting all those anomalous experiences incessantly which, despite all therapeutic attempts made, persisted until that time. During her crises, she used neuroleptics at low dosages and, if necessary, antidepressants, as she frequently showed important depressive symptoms.

As time passed, I started noticing that she usually worsened during premenstrual times and it dissipated entirely afterwards. The patients had always been reluctant to accept any therapeutic with lithium carbonate and had never taken it for over a month, claiming weight gain. So far, she has accepted to use valproic acid (1g/day) associated with clomipramine (75 mg/day) showing a visible general improvement. She was calmer and more stable, although her tenuous ideas of homosexuality persisted rarely and episodically. As for her work, after having many disagreements in her professional environment caused by motiveless distrust and suspicions, she was given a sick leave for some months. On those occasions of disagreements with her colleagues and school directors, she was extremely querulous and whiny and would write long letters denouncing supposed administrative irregularities and hypothetical injustice done to her. She got married in 1998 and, in the same year, was graduating in Psychology, despite several difficulties.

For several years, she has been abusing benzodiazepines sporadically, in particular on those occasions when she has arguments with her husband or when her affective instability intensified. Thoughts of homosexuality and that she is being observed still come into her mind at times and she sometimes believes people think and 'comment' her husband also has a 'homosexual manner'. She has recently gone through false perception ¾ or hypnagogic hallucination ¾ towards her husband, as she believed, based on some rhythmic movements of their bed, he masturbated himself while lying in bed beside her. Data of the factual reality confronted later contradicted such impression. On the occasion, she was prescribed pimozide (2 mg/day), but did not tolerate due to somnolence and sedation. Apart from that, I.G. was pleased and in so far as possible happy. Sexually speaking, she gets on well with her husband, except in those short periods when she is disturbed by those anomalous experiences and during which she becomes distrustful, irritable and taciturn.

DISCUSSION

In regard to the first clinical case, we can state that, according to DSM-IV(2), K. probably has a Delusional Disorder.

The first episode of the disease happened unexpectedly and early, in his twenties, but it was rather typical, considering its peculiar phenomenology which matches with a clinical subtype of delusional jealousy. False illusion of the perceptual and memory processes are common in those cases as well as delusional experiences which can be, as in the case mentioned, fleeting, mutable and little systematised(8). As regards that, we can point out that K. firmly believed, with irrefutable intimate conviction, that his girlfriend was having a relationship with another woman, more precisely, with her maid. According to him, those 'proofs', uncontestable 'evidences', consisted in apprehending some daily 'facts' which, for us, consist of fragments of false illusional perception, delusional perceptions and experiences. Therefore, the malicious sentences, the gaze full of obscure intentions, the 'pale' skin after a hypothetical orgasm, all those facts string together logically and orderly in the patient's mind and provide the meaning of new delusional convictions.Apart from delusional experiences, in the case discussed, it is likely K. also experienced rare hallucinations of olfactory nature. When talking about 'a lingering smell, typical of coloured people', it seems that K. was referring to an experience with a high degree of sensorial vigour whose nature is closer to a new perceptive experience than to an false illusional perception. Moreover, hallucinatory experiences are not rare in the clinical development of delusional disorders(22).

As for K's other delusional episodes, we can affirm that the same psychopathologic elements already discussed formed and framed the specific phenomenological trauma of all of them. After his first psychotic crisis, K. lived an acute persecutory delusional episode, consisting of massive delusional perceptions, apparently triggered by stressful emotional circumstances of threaten and danger. In regard to his anomalous experiences, it is worth mentioning that the delusion stems from a deep change in judgement or judging capability, allowing the appearance of erroneous, false and distorted ideas or convictions. Thus, the delusion is essentially an anomalous conviction or judgement, a kind of false assumption from which false conclusions are drawn, untruthful ramifications whose main characteristics are incorrigibility, unshakeable personal belief and unlikeliness of the content(5,9).

After that persecutory psychotic episode or at about the same time, K. seems to have developed a variant of delusional jealousy towards his wife, which had been occurring chronically and intermittently. Therefore, the same psychopathological elements mentioned earlier seems to multiply and intensify in his experiences from time to time, consolidating the suspicions, false mneme and perceptions, and anomalous judgements lived previously. Apparently, according to his accounts, K. seemed to have developed great personal conviction about the likelihood of his anomalous experiences. We can say that his intimate belief in them remained uniform and without any visible fluctuation, except on those occasions of subacute exacerbation of his clinical picture.

In K.'s case, we can take into account the association of alcoholism with a delusional picture, considering his reporting of alcohol abuse since adolescence until two years before. JASPER(8) claims that KRAFT-EBING found delusional jealousy in 80% of the drinkers who were still sexually active and explained its relation with the somatic and mental consequences of alcohol abuse (increase in libido concomitant with decrease in sexual potency, marital difficulties, contempt from the wife, etc.). Moreover, the delusion would come up in a combined manner, taking into consideration several factors in its genesis, such as naive and fortuitous comments, the special peculiarity of an alcoholic's affectivity, dementia, a kind of sexual deterioration and incontinence, and feeble foundation of judgement. Furthermore, by refraining from alcohol and keeping the abstinence, it would be possible to obtain, if not the cure, a satisfactory improvement, although it could be interrupted by intercurrent outbursts of delusion(8).

However, in K.'s case, the alcoholic abuses seemed to be sporadic and were supposed to reduce his social anxiety and shyness. In the interview, I did not detect any data to confirm important periods of symptomatic intoxication or abstinence. Nor were there signs or evidences of mental, somatic, social, occupational or existential damage caused by long and massive use of alcohol. Thus, in this case, it seems reasonable to agree with DSM-IV and regard it as Primary Psychotic Disorder (Delusional Disorder) instead of a supposed Psychotic Disorder Induced by Substance with Delusion (2).

As regards the differential diagnosis, it is necessary to point out that the nosologic relations between delusional disorders, schizophrenias and affective diseases(10-14, 21,22) have been intensively investigated for about twenty years. Since KRAEPELIN time, some authors have considered delusional disorders either as clinical forms of affective diseases or 'mild' forms of schizophrenia. Today's research seems to point to the autonomy of delusional disorders which coincides with KRAEPELIN's concept of separating paranoia, as a clinical entity, from 'dementia praecox' and manic-depressive illness. KENDLER(10-14) consistent work has reached the conclusion that surrounding factors can be more important for the etiology of delusional disorders than those constitutional-genetic ones, as opposed to schizophrenias, what had already been recognised by KRAEPELIN(10). On the other hand, in previous studies, the pre-morbid personality of patients with delusional disorder seems to consist mostly of traits of extroversion, hypersensitive and domineering tendencies, in contrast with schizophrenic patients whose pre-morbid personality shows predominantly schizoid traits and tendency to introversion and submission(11). JASPER(8) had already observed such evidence when analysing meticulously the clinical history of two patients with delusional jealousy­. He states that '... both personalities show a symptomatic complex comparable to hypomanics: constant self-affirmation never denied, easy excitability, tendency to either rage or optimism or occasional contradictions and constant activity. Pleasure in their activity ...' After concluding that those patients' anomalous experiences were phenomenologically 'incomprehensible' and underivable, as they did not come from the 'development' or hypertrophy of any important trait of their personality, this same author claims that the disease corresponds to a 'circumscript process', taking into account the total preservation of their personality even after years of clinical development(8).

Regarding I.G.'s case, it seems reasonable to say, according to DSM-IV(2), that the patient has important traits of Borderline Personality Disorder, such as affective instability due to marked mood reactivity, liability to disorder of impulse control, identity disturbance and fantasies of genital self-mutilation. In addition, she also satisfies the criteria for Body Dysmorphic Disorder, although the guide mentioned claims that some borderline patients can develop psychotic symptoms characterised by hallucinations, distortion of corporal image and hypnagogic phenomena(2). Concerning that, several authors are unanimous in their opinion about the unspecificity of the psychotic symptoms manifested by those patients(7,16,17,19,25,29,31). There are also important evidences of frequent comorbidity and nosological relation(2,28) between Borderline Disorders and Mood Disorders.

As far as this patient's accounts are concerned, we could ask whether her delusional experiences coincide with the strict standards shown by classical delusion, that is to say, intimate belief, incorrigibility and unlikelihood, as discussed above. The answer is no when we consider the constant fluctuations along a broad spectrum of subjective belief, of her intimate conviction about the likelihood of her experiences. Even in the first and remarkable psychotic episode, her delusional experiences were on one hand phenomenologically 'incomprehensible' and underivable in the jasperian sense(8,9), corresponding to something 'new' and unusual, and on the other hand, were partially refutable and flexible as a whole, making her self-criticism of its likelihood oscillate enormously. This does not happen to the primary schizophrenic delusion, which strictly keeps those attributes in a regular and permanent way. As time passed, I.G. experienced a gradual transition ranging from over-valued judgements to delusional ones as well as false illusional perceptions and mneme and, probably, hallucinations. In contrast, in an evolutive clinical view, we can panoramically observe a kind of paranoid development of her personality ¾ or perhaps, a 'circumscript' process ¾ in JASPERS's sense(8), which symptomatologically and acutely led to the patient's first psychotic episode and continued manifesting along her existence chronically and intermittently. Thus, she kept a active basal behaviour tending to claims and belligerence and, in the moments when her clinical picture exacerbated, took some attitudes which reminded KRAEPELIN(8)'s description of pseudoquerulous patients. As if that was not enough, even in the intercritical periods of the disease, when she was apparently asymptomatic, I.G. harboured doubts about the likelihood of some painful 'convictions' which tormented her. For instance, in those periods, although she did not notice people looking at her and commenting something discreditable about her, she would still consider they would continue doing it 'disguisedly'. Therefore, we could visualise, taking into account the phenomenological nuances of I.G.'s clinical history, a kind of minor or subacute delusional disorder, perhaps frustrated and unsuccessful, but which, like complete and classical clinical forms, progresses along the patient's life bringing great loss and pain.

For the last thirteen years, I have had the opportunity to observe and analyse meticulously a wide range of anomalous experiences related by I.G. and, in my opinion, from the phenomenological point of view, most of them are atypical and uncharacteristic. On many occasions, she would complain about suddenly feeling 'weird' and 'ridiculous' and noticing people suspect she was 'homosexual' and 'transvestite'. In those moments, the psychopathological material was similar to obsessive phenomena, considering its intrusive and persistent character. In others, those anomalous experiences looked like delusional perceptions, as for example, one day when she asked for an urgent appointment claiming that an 'amazing revelation' had happened. She had been to a certain place and noticed that everyone 'confirmed' her 'homosexuality' by 'exchanging squints and making some gestures'.

Apart from that, she would feel 'her feelings confused and incoherent' as well as 'envy, distrust, hatred, irritation and distress', according to her own words. In addition, in some periods, episodes of depersonalisation and derealisation intensified. At first glance, it is reasonable to think that all those experiences reported by I.G. are related to those well-known schneiderian symptoms(24) which sometimes manifest in schizophrenic psychoses, given their similarity in phenomenological structure. Therefore, delusional perceptions, delusional events, other pseudo-perceptions, feelings of perplexity and strangeness(24,27) and the bleulerian symptom(3) of ambivalence can be identified in I.G.'s accounts, but uncharacteristically and sparsely, as if it were a symptomatological expression, for some reason, frustrated and unsuccessful.

It is interesting to observe that the phenomenology of I.G.'s experiences differs in depth and severity from the one corresponding to the actual primary delusion(9), raw material for delusional events (wahneinfall)(24), usually seen in schizophrenic patients. In it, as well as in typical delusional perceptions (wahnwahrnehmung)(20,24), there is a 'revelation' character, 'something moving, transcendental, a sign or message coming from another world'(24). On the other hand, the anomalous experiences reported by I.G. were described as something that seemed to be, but never as something that actually was. Her intimate conviction of the likelihood of her experiences fluctuated clearly as time passed and occasionally alternated between high and low intensity, even on one single day. In addition, I.G.'s accounts were loaded with drama and followed by an outburst of tears, grand gestures, lively mimic and strong emotions of anger, distress and unconformity. However, the psychopathological morphology of the patient's psychotic phenomena presented itself as a set of phenomenological sketch of those complete and classical symptoms, similar to something morbid and more serious. But, for some reason, it had not arisen entirely and as a result manifested atypically and uncharacteristically. Some aspects of her clinical morphology were so mutable and phenomenologically indefinite that, in contrast, could consist in a multiform psychopathological expression of a real nosological spectrum, ranging from what is considered to be a personality disorder to a minor delusional disorder.

In another paper(26), we have already claimed that, in our opinion, the anomalous experiences which predominates in atypical psychotic pictures consist phenomenologically of frustrated, unsuccessful or abortive symptoms of psychopathological expressions typical and characteristic of well-defined psychoses which, in turn, stem from two basic endogenous approaches ¾ schizomorph or affective. On that occasion, we proposed the term psychoid states or disorders(26) to name those psychotic clinical pictures characterised by marked atypicality and phenomenological indefiniteness. Having this concept in mind, it seems reasonable to think that I.G.'s clinical picture corresponds to an incomplete and concomitant outbreak of the two genetic approaches mentioned above, taking into consideration that the periodically cyclical appearance of her schizomorph symptomatology has a subacute character and a clinical history that, on one hand, damages the unity of her existence but, on the other hand, is much more benign and complacent than the one typical of better-defined and characterised clinical forms of general psychotic disorders.

Those theoretical concepts can perhaps help clinical thinking when diagnoses are made in daily psychiatric practice and consequently enable the early adoption of therapeutics capable of reliving symptoms of patients with complex and resistant psychiatric disorders. In our opinion, it is only by presenting clinical cases in details and discussing them carefully we can clarify the several obscure questions inherent in the nosological borders of Psychiatry and hence contribute to dissipating an involuntarily static and compartmentalised view of psychic impairment. In this respect, to conclude, it is useful to mention some explanatory words of KRAEPELIN concerning the analysis of clinical cases(8): 'Consciously disaggregating clinical forms into its most minute and apparently insignificant variations is the indispensable prior stage for acquiring nosological images of actual unique diseases and which corresponds to its actual nature.'

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­ JASPERS, K. ¾ 'Escritos Psicopatológicos' , Published by Gredos, Madrid, 1977 (in Portuguese). (Originally written in 1910): See the clinical case reports of Julius Klug and Max Mohr ¾ Pages 111 to 143.